1. College of Public Health
Integration of Social, Cultural, and Biomedical Strategies into an Existing Couple-Based Behavioral HIV/STI
Prevention Intervention: Voices of Latino Male Couples
Omar Martinez, JD, MPH, MS1; Elwin Wu, PhD2; Ethan C. Levine, MA1; Eva Moya, PhD3; Silvia Chavez-Baray, PhD3; Alex Carballo-Dieguez, PhD4;
M. Isabel Fernández , PhD5; Miguel Munoz-Laboy, DrPH1; Larry Icard, PhD1; Justin Manusov, JD(c) 6; Hugo Ovejero, JD7; Andrew Shultz, MA8; Timothy Frasca, MPH4; Scott D. Rhodes, PhD9
1School of Social Work, Temple’s College of Public Health; 2Social Intervention Group, Columbia University; 3University of Texas-El Paso; 4HIV Center, Columbia University;
5Nova Southeastern University; 6University of Colorado Law School; 7Lutheran Family Health Centers; 8Catholic Migration Services; 9Wake Forest University
College of Public Health
Abstract
Introduction
Results
Introduction: Successful HIV prevention and treatment requires evidence-based approaches that incorporate biomedical strategies and are culturally appropriate for target populations. The need for effective combination approaches is particularly pronounced for men who have sex with men (MSM), who face a disproportionately high risk of HIV acquisition. However, best practices for incorporating biomedical strategies within behavioral interventions remains unclear. Materials and Methods: We adapted Connect ‘n Unite, an evidence-based behavioral HIV/STI prevention intervention originally developed for Black MSM couples, for predominantly Spanish-speaking Latino MSM and Latina transgender women and their male partners. We used a qualitative research design involving three focus groups with couples (n=20 couples, or 40 individuals) and one with providers (n=10). Participants offered insights for integrating social, cultural, and biomedical components into a couple-based HIV/STI behavioral intervention. Through social media and community-based strategies, we recruited a diverse group of couples in terms of country of origin, HIV status, time in the US, sexual and relationship dynamics, and substance use. Results: The adapted intervention, Conectando Latinos en Pareja, integrates social, cultural, behavioral and biomedical strategies to address HIV among Latino MSM. Most participants (N=37) had no prior knowledge of the following biomedical strategies: non-occupational post-exposure prophylaxis (nPEP), pre-exposure prophylaxis (PrEP), and HIV self-testing kits. After learning of these tools, all participants expressed a need to empower Latino MSM through raising awareness of and access to them. In particular, participants suggested that we provide PrEP and HIV self-testing kits by the middle or end of the intervention. Providers echoed these recommendations, and further suggested a need to address behavioral, social and structural issues, such as language barriers; and to promote client-centered approaches to increase access to, adaptation of, and adherence to biomedical strategies. Regarding culturally sensitive and responsive approaches, participants identified stigma and discrimination associated with HIV and sexual identity as barriers to care, language barriers and documentation status as further barriers, the couple-based approach as ideal for health promotion, and expressed a need to include family topics in the intervention. Conclusion: We successfully adapted an evidence-based behavioral HIV prevention intervention for Latino MSM couples. This study provided promising data regarding the feasibility of implementing a combination approach to HIV prevention for this population.
In 2011, Latinos in the US represented 21% of new HIV infections (10,159), while comprising only 16% of the US population. Latino men who have sex with men (MSM) faced an especially heavy burden, representing 72% (7,266) of new HIV infections among Latinos. For Latino men infected with HIV, the most common modes of transmission were male-to-male sexual contact and injection drug use.
Some behavioral interventions have been developed specifically to address HIV among Latinos (e.g., HoMBReS, Proyecto SOL), including some targeting predominantly Spanish-speaking Latino MSM (e.g., HOLA). These interventions have examined behavioral and structural influences on HIV care and testing, such as unprotected anal intercourse and obstacles to accessing health services. However, none have incorporated newly available biomedical strategies (e.g. nPEP, self-testing kits, PrEP for HIV- and TasP for HIV+ individuals). Thus, there is a great need to investigate the effectiveness of combination prevention strategies that integrate behavioral, structural and biomedical approaches to reducing HIV incidence, while providing tools to address the larger HIV epidemic.
Building on the promise of these interventions and the need for comprehensive approaches to prevention and treatment, we wanted to identify strategies for incorporating biomedical tools into a couple-based, behavioral HIV prevention intervention for predominantly Spanish-speaking Latino MSM—a population at high risk of HIV infection. To that end, we developed Conectando Latinos en Pareja. To our knowledge, ours was the first study to assess the potential of a combined biomedical, social, and structural approach to addressing HIV in this population.
Integration of Biomedical Approaches
What about the needs of serodiscordant couples? We need more information about PrEP. We should be talking about these things. Couples are tired of using condoms and information about biomedical tools can help a lot of people (Carmelo, ID26).
If I had access to a self-test 20 years ago when I saw a friend of mine die of AIDS, I would have gotten tested a long time ago. But it was fear and shame of having a doctor tell you to your face ‘You have AIDS, you faggot (puto)’ that kept me from going and getting tested (Juan, ID37).
We need to educate participants from the beginning of the intervention about biomedical interventions, in particular through adherence information. PrEP should be an incentive towards the latter part of the study, once participants have received information, knowledge, and counseling around PrEP. However, PrEP shouldn’t be passed out like candy and should especially be promoted for serodiscordant couples (Provider, ID8).
Just because something is written in Spanish does not mean it is culturally competent. Beyond speaking Spanish, a provider must be caring to clients and meet their needs and be culturally competent while still dealing with paperwork and the demanding environment of care provision (Provider, ID1).
Building Culturally Sensitive and Socially Grounded Interventions
When I changed my name, a nurse insisted on calling me ‘he’ and that made me uncomfortable, since I consider myself a woman (Maria, ID2).
I have been to a lot of workshops but they have always focused on individuals and single gay men, and this is one that focuses on the couple context as an approach to promote health, and this was interesting to me (Carlos, ID6).
I feel that immigration status is always an important issue for couples and people, and it can be difficult to be healthy or have access to health care because of it [immigration status] (Carolos, ID9).
Methods
We conducted three focus groups with 20 Latino MSM couples and one with 10 providers. Focus groups lasted approximately 2-3 hours and were audio recorded. Participants provided informed consent and were given the option to use pseudonyms to protect their privacy. The PI and a co-author facilitated discussions while note-takers captured nonverbal information and ensured that comments were accurately attributed. All discussions were conducted in Spanish. Facilitators and note-takers debriefed after each session, and their reflections were recorded.
Open-ended questions for couples explored knowledge and perceptions of biomedical strategies, experiences in accessing these tools, and suggestions regarding how to incorporate them into a couple-based behavioral HIV/STI prevention intervention. Providers were asked which biomedical strategies seemed most useful for a couple-based behavioral HIV prevention for Latino MSM, and how these strategies could most effectively be integrated into behavioral interventions. We continued to elicit dialogue from focus groups until no new information resulted.
Conclusion
Overall, couples and providers recommended having access to and information about three biomedical approaches – nPEP, PrEP, and HIV self-testing kits – and supported integrating these approaches into the existing behavioral intervention. These findings contribute to the growing literature on the importance of integrating biomedical and behavioral approaches to HIV prevention among vulnerable groups. Our research strategy might be extended to other behavioral interventions with new biomedical tools, provided that researchers and practitioners adapted those interventions and sought out interactive, effective feedback from targeted communities.
References
Martinez, O., Wu, E., Shultz, A., Capote, J., López Rios, J., Sandfort, T., & ... Rhodes, S. (2014). Still a hard-to-reach population? Using social media to recruit Latino gay couples for an HIV intervention adaptation study. Journal Of Medical Internet Research, 16(4), e113.
Martinez, O., Wu, E., Sandfort, T., Shultz, A. Z., Capote, J., Chávez, S., & ... Ovejero, H. (2014). A couple-based approach: An innovative effort to tackle HIV infection among Latino gay men. Ehquidad,
Martinez, O., Wu, E., Frasca, T., Shultz, A. Z., Fernandez, M. I., López Rios, J., & ... Sandfort, T. M. (2015). Adaptation of a Couple-Based HIV/STI Prevention Intervention for Latino Men Who Have Sex With Men in New York City. American Journal Of Men's Health, DOI: /
Acknowledgments
This research was supported by a center grant from the National Institute of Mental Health to the HIV Center for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University (P30-MH43520; Principal Investigator: Robert H. Remien, Ph.D.). Mr. Omar Martinez was supported by a training grant from the National Institute of Mental Health (T32 MH19139, Behavioral Sciences Research in HIV Infection; Principal Investigator: Theo Sandfort, Ph.D.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the NIH.
Omar Martinez